💊 New Lesson 29
Mental Health Medications
SSRIs, TCAs, MAOIs (tyramine), antipsychotics, lithium toxicity, NMS, serotonin syndrome.
Antidepressants
Antidepressant Classes
| Class | Examples | Key Side Effects / Teaching |
|---|---|---|
| SSRIs | Fluoxetine (Prozac), Sertraline (Zoloft), Paroxetine (Paxil), Citalopram (Celexa) | 2-4 weeks for full effect. Headache, nausea (transient), sexual dysfunction. ⚠️ Monitor 18-24 yr-olds for increased suicidal ideation in early treatment. |
| SNRIs | Venlafaxine (Effexor), Duloxetine (Cymbalta) | Block reuptake of serotonin AND norepinephrine. Nausea, hypertension possible. |
| TCAs | Amitriptyline (Elavil), Imipramine (Tofranil) | Anticholinergic: dry mouth, constipation, urinary retention, sedation. Overdose risk is HIGH. |
| MAOIs | Phenelzine (Nardil), Tranylcypromine (Parnate) | ⚠️ AVOID tyramine foods (hypertensive crisis). 2-week washout period required. |
🚨 SEROTONIN SYNDROME vs NMS:
Serotonin Syndrome = serotonergic drugs → hyperreflexia + clonus + fever + altered MS → ER immediately
NMS = antipsychotics → LEAD-PIPE rigidity + high fever + autonomic instability → STOP antipsychotic, critical care
Key difference: HYPERREFLEXIA (serotonin) vs RIGIDITY (NMS)
Serotonin Syndrome = serotonergic drugs → hyperreflexia + clonus + fever + altered MS → ER immediately
NMS = antipsychotics → LEAD-PIPE rigidity + high fever + autonomic instability → STOP antipsychotic, critical care
Key difference: HYPERREFLEXIA (serotonin) vs RIGIDITY (NMS)
MAOI Dietary Restrictions — Tyramine Foods to AVOID
❌ Aged cheeses (cheddar, brie, blue cheese)
❌ Cured/processed meats (salami, pepperoni, bacon)
❌ Red wine and beer
❌ Sauerkraut, soy sauce, miso, kimchi
❌ Overripe or fermented fruits
❌ OTC decongestants with pseudoephedrine
⏰ 2-week washout period when switching between MAOIs and other antidepressants
❌ Cured/processed meats (salami, pepperoni, bacon)
❌ Red wine and beer
❌ Sauerkraut, soy sauce, miso, kimchi
❌ Overripe or fermented fruits
❌ OTC decongestants with pseudoephedrine
⏰ 2-week washout period when switching between MAOIs and other antidepressants
Antipsychotics
Antipsychotics — Traditional vs Atypical
| Feature | Traditional (1st Gen) | Atypical (2nd Gen) |
|---|---|---|
| Examples | Haloperidol (Haldol), Chlorpromazine (Thorazine), Fluphenazine (Prolixin) | Aripiprazole (Abilify), Clozapine (Clozaril), Risperidone (Risperdal), Olanzapine |
| Symptoms Treated | POSITIVE ONLY | BOTH positive AND negative |
| EPS Risk | HIGH | Lower |
| Special Monitoring | AIMS screening | Clozapine: WEEKLY CBC (agranulocytosis) |
EPS Side Effects — Know All 4!
| EPS Type | Signs | Timing |
|---|---|---|
| Akathisia | Restlessness, inability to sit still | Early onset |
| Acute Dystonia | Painful muscle spasms (face, neck, back) | Early onset (hours to days) |
| Pseudoparkinsonism | Pill-rolling tremor, shuffling gait, rigidity, bradykinesia | Weeks |
| Tardive Dyskinesia | Lip smacking, tongue protrusion, grimacing, blinking | LATE (months-years) — potentially IRREVERSIBLE |
🚨 Neuroleptic Malignant Syndrome (NMS):
Signs: HIGH FEVER (>100.4°F), SEVERE MUSCLE RIGIDITY, autonomic dysfunction, altered MS
Action: STOP antipsychotic IMMEDIATELY → transfer to critical care
Signs: HIGH FEVER (>100.4°F), SEVERE MUSCLE RIGIDITY, autonomic dysfunction, altered MS
Action: STOP antipsychotic IMMEDIATELY → transfer to critical care
Mood Stabilizers
Lithium Therapy — Must Know!
| Level | Meaning | Signs |
|---|---|---|
| 0.8-1.2 mEq/L | THERAPEUTIC | Fine hand tremor (expected side effect) |
| >1.5 mEq/L | EARLY TOXICITY | COARSE tremor, N/V/D, polyuria, muscle weakness, slurred speech |
| >2.0 mEq/L | SEVERE TOXICITY | Ataxia, seizures, cardiac arrhythmias — POTENTIALLY FATAL |
⚠️ Fine tremor = expected side effect of lithium
🚨 COARSE tremor = TOXICITY — Hold and notify HCP immediately
💧 Adequate sodium and fluid intake is essential (water follows Na+)
🚨 COARSE tremor = TOXICITY — Hold and notify HCP immediately
💧 Adequate sodium and fluid intake is essential (water follows Na+)
Alcohol Withdrawal Medications
Chlordiazepoxide (Librium) = first-line for acute alcohol withdrawal (prevents seizures and DTs)
Disulfiram (Antabuse) = alcohol deterrent — causes severe reaction with ANY alcohol
Naltrexone = reduces alcohol cravings
Acamprosate calcium = helps maintain abstinence
Disulfiram (Antabuse) = alcohol deterrent — causes severe reaction with ANY alcohol
Naltrexone = reduces alcohol cravings
Acamprosate calcium = helps maintain abstinence
📖 Notes for Dummies
📖 Psych Meds Explained Simply
💊 SSRIs in Plain English:
Think of serotonin like water in a sink. The reuptake pump drains it away too fast. SSRIs block that drain so the serotonin stays longer. Takes 2-4 weeks because you're slowly adjusting the brain chemistry — not a light switch.
⚡ Lithium in Plain English:
Fine (mild) tremor = normal — the medication is working. COARSE (severe, shaking) tremor = DANGER. Level above 1.5 = toxic. Lithium is very picky about salt — if the patient doesn't eat enough salt or fluids, the lithium level rises (toxicity risk). If they eat more salt, level drops (less effective). Stable diet = stable level.
🔴 NMS vs Serotonin Syndrome in Plain English:
NMS = antipsychotics. Think RIGID (stiff as a board) + HOT (high fever). This is the antipsychotic turning the muscles into concrete. Serotonin syndrome = SSRIs/MAOIs combined or overdosed. Think JUMPY (hyperreflexia, clonus, agitated) + HOT (fever). The body is overloaded with serotonin. Both are emergencies — just remember: rigid = NMS, jumpy = serotonin.
🍷 MAOI + Cheese in Plain English:
MAOIs block the enzyme that breaks down tyramine. Tyramine builds up in the blood, causes the blood vessels to clamp down hard — severe hypertension with a splitting headache. People have stroked out eating cheese on an MAOI. No aged cheese, no red wine, no cured meats. Period.
Think of serotonin like water in a sink. The reuptake pump drains it away too fast. SSRIs block that drain so the serotonin stays longer. Takes 2-4 weeks because you're slowly adjusting the brain chemistry — not a light switch.
⚡ Lithium in Plain English:
Fine (mild) tremor = normal — the medication is working. COARSE (severe, shaking) tremor = DANGER. Level above 1.5 = toxic. Lithium is very picky about salt — if the patient doesn't eat enough salt or fluids, the lithium level rises (toxicity risk). If they eat more salt, level drops (less effective). Stable diet = stable level.
🔴 NMS vs Serotonin Syndrome in Plain English:
NMS = antipsychotics. Think RIGID (stiff as a board) + HOT (high fever). This is the antipsychotic turning the muscles into concrete. Serotonin syndrome = SSRIs/MAOIs combined or overdosed. Think JUMPY (hyperreflexia, clonus, agitated) + HOT (fever). The body is overloaded with serotonin. Both are emergencies — just remember: rigid = NMS, jumpy = serotonin.
🍷 MAOI + Cheese in Plain English:
MAOIs block the enzyme that breaks down tyramine. Tyramine builds up in the blood, causes the blood vessels to clamp down hard — severe hypertension with a splitting headache. People have stroked out eating cheese on an MAOI. No aged cheese, no red wine, no cured meats. Period.